Health Care Reform Center

Gillian K. SteelFisher, Ph.D., Robert J. Blendon, Sc.D., Tara Sussman, M.P.P., John M. Connolly, M.S.Ed., John M. Benson, M.A., and Melissa J. Herrmann, M.A.

In 2006, Massachusetts enacted the country’s first law mandating near-universal health care coverage,¹ and the state now has the lowest proportion of uninsured residents in the United States. The Massachusetts Division of Health Care Finance and Policy estimated that only 2.7% of state residents remained uninsured as of spring 2009.² National policymakers have turned to Massachusetts as a potential model for federal health care reform, and reform proposals recently put forward in Congress include elements from the Massachusetts plan, such as the individual mandate to buy insurance, public-program expansions, and a health insurance exchange.

Despite the state’s low percentage of uninsured residents, national reviews of the Massachusetts reform have been mixed, especially in recent months. Although some reports have drawn attention to the state’s insurance gains and indicated that health care costs, though growing, have not exceeded early projections or expectations, others have argued that high costs and some reported problems with access to care should be taken as warnings of the problems the country might face if a similar reform were implemented nationally. For example, Michael Tanner of the Cato Institute has called the Massachusetts reform “unsustainable” because of its “failure to restrain the growth in health care costs” and the fact that it has “set the stage for . . . price controls and explicit rationing.”³ Similarly, a June 24, 2009, post about the Massachusetts reform on the blog of John Boehner of Ohio, the Republican leader in the U.S. House of Representatives, said that “out of control costs” and “rationing” have been consequences of universal coverage in Massachusetts.

We know from previous research that the Massachusetts public is favorable toward the state’s legislation,⁴ but physicians can provide critical insight into how the law is actually functioning and how it has affected access to high-quality health care. In previous studies, Massachusetts physicians have been interviewed about their experiences with and impressions of other reform issues, such as managed care and a potential single-payer health care system, but only one poll to date has asked physicians about Massachusetts health care reform. That online poll, conducted by the American College of Emergency Physicians, focused on the views of 138 emergency doctors. Its results suggest that reform in Massachusetts is putting pressure on emergency room capacity.⁵ In a poll we conducted with support from the Robert Wood Johnson Foundation and the Blue Cross Blue Shield of Massachusetts Foundation, we turned to physicians in Massachusetts more broadly to assess their perceptions in three areas: their overall support for the legislation, their views of its effect on their own practice, and their views of its effect on health care throughout the state (see Poll Methods).

Of 2135 practicing Massachusetts physicians who responded to the poll, 70% said they support the Massachusetts Health Care Reform Law, whereas 13% oppose it (see Table 1). The levels of support among primary care doctors and among specialists were similar. When asked about the law’s future, 75% indicated that they want the law to remain in place — 46% with some changes, and 29% as is. Seven percent favored repealing the legislation. Physicians who mentioned that some changes are needed were asked in an open-ended question what change they would most like to see. They most frequently mentioned issues related to expanding coverage (34%) and addressing the costs of the program (23%). Approximately three quarters of Massachusetts physicians (79%) reported being very or somewhat satisfied with their medical practice. Fifty percent reported that things at their practice had gotten worse over the past 3 years, and 23% said things had gotten better. Few said that the Massachusetts health care reform law was a major reason for positive changes (13%) or negative ones (11%).

We also asked physicians about 22 aspects of their practices that might be affected by the law. Table 2 shows the responses in descending order of the number of negative responses. In 21 of these areas, a majority of physicians said that the law either did not have much of an effect or was having a positive effect on their practice. These include areas that have been important in the health care reform debate: the quality of care their patients receive (85%), their medical practice overall (79%), the amount of time their patients wait to get an appointment (62%), and the financial situation of their practice as a whole (56%). Forty-eight percent of physicians said that the law was decreasing the number of patients in their practice who were uninsured, which was the highest percentage of positive responses regarding any practice area. Forty-two percent reported that it was positively affecting their uninsured patients’ ability to pay for care. The aspect that elicited the most negative response was the law’s administrative burden on their practice; 35% of physicians said the law was negatively affecting this area. About one quarter of physicians reported negative effects in the overall cost of care for patients, their financial situation, and the amount of time patients wait for an appointment.

As for the broader effects on the state, 3 years after implementation of the law, Massachusetts physicians rate the state’s health care system positively. Nearly twice as many physicians rate the Massachusetts system for providing medical care as excellent or good as rate the national system that highly (63% vs. 33%) (see Table 3).

In this section of the poll, we also asked physicians to assess the impact of the law on health care in the state as a whole. We queried them about 10 aspects of health care in Massachusetts that might be affected by the law. Table 3 shows the responses in descending order of the number of negative responses. In 9 of these 10 aspects, a majority or plurality said that the law either did not have much of an effect or was having a positive effect on the situation in the state. For example, more than three quarters of physicians (79%) believed the law was positively affecting people who had not had health insurance before the law went into effect. The second most positively affected aspect was the quality of care in Massachusetts (with 37% reporting that the law was helping). The one feature of the law’s impact that received negative evaluations from a majority of physicians (53%) concerned the overall cost of care in the state. The next most negatively affected aspect was patients’ ability to see a primary care provider (with 34% reporting that the law was hurting that), although nearly as many physicians reported that the law was helping in this area (29%). More than 25% of physicians said they did not know what effect the law was having on each of five areas: the overall cost of care in Massachusetts, the cost that Massachusetts patients pay, primary care practices, hospitals, and specialty practices.

Massachusetts has the lowest proportion of uninsured residents in the United States. Our results show that there is widespread support among Bay State physicians for the law that led to this high level of coverage. At the same time, physicians believe that it has contributed to some problems with health care in the state.

Examination of physicians’ views on care for their patients provides little evidence to support criticisms that the law is negatively affecting the quality of care that most physicians deliver. With regard to their own practices, a sizable minority of physicians indicate that the legislation has increased their administrative burden.

Physicians’ views concerning the effect of the law on the state’s health care environment are more mixed. Most believe it is helping the formerly uninsured, but that positive view is coupled with a majority belief that the program is driving up the cost of health care in the state. In addition, physicians are divided about whether it has imposed pressures on the state’s primary care capacity.

Taken together, these findings suggest that it is possible both to provide near-universal coverage of the population and to have a system that most physicians believe improves care for the uninsured without undermining their ability to provide care to their patients. At the same time, the Massachusetts experience provides evidence of trade-offs in other areas of the health care system, including rising health care costs and, for some patients, challenges in obtaining access to primary care.

Poll Methods

Study Design and Fielding

The poll was designed and analyzed by a team of researchers at the Harvard School of Public Health. The fielding process was coordinated by an independent survey research firm, Social Science Research Solutions.

Sources of Data

The data are from a randomized poll of 2135 Massachusetts physicians. Researchers obtained a random sample of physicians practicing in Massachusetts from the SK&A database, which is a comprehensive list of physicians based on published association and trade directories as well as federal and state license files. Information in the directory is updated and verified every 6 months.

Physicians were invited to participate in the study by means of a mailed letter and were offered an incentive ranging from $50 to $100 for completing the poll. The incentive amount was determined by the physician’s specialty, as is standard practice in polls of physicians. All respondents were offered the opportunity to complete the poll by mail, Internet, or telephone; all chose mail or Internet.

Poll Questions

A complete list of questions asked as part of the poll is available in the Supplementary Appendix, available with the full text of this article at NEJM.org.

Data Collection and Statistical Analysis

The poll was conducted from August 11 to September 15, 2009. This period was chosen to help ensure the relevance of the data to the national debate on health care reform. Congress had originally been expected to vote on a health care reform bill in October 2009. The period was short to ensure that we captured views during a relatively uniform period that was less likely than a longer period to be interrupted by changes in the environment, such as media reports on the issue, that might affect physicians’ views differentially over time. We issued a higher number of initial mailings and predicted a lower response rate than in longer-term surveys, and we used weighting techniques to ensure that the final responses reflect the views of the overall physician population. This approach is similar to standard techniques for polls of the public. It has been shown to be more accurate than surveys of the public with longer field times for issues that are sensitive to changes in media coverage, such as election campaigns. Independent studies have shown that statistically weighting the data for known population variables reduces the effects of a lower response rate.^1,2

More physicians wanted to participate in the poll than we had expected, so we allowed those who wanted to complete the poll after the deadline to submit their responses with the understanding that they would not be provided with an incentive. We compared the demographic profiles of those who responded within the window when incentives were offered to the profiles of the full sample and to the profiles of all physicians in Massachusetts. We found few differences in either comparison, although both of our samples include a smaller fraction of medical subspecialists than the population of Massachusetts physicians does. We also compared responses to a key substantive question (whether the respondent supports or opposes the legislation) between our two samples and did not find a significant difference in the level of support for the legislation.

To ensure that we used a representative sample, our analysis weighted the final sample to reflect the composition of Massachusetts physicians. Characteristics included in the weighting were specialty, regional location, and setting of practice (urban, suburban, or rural).

When interpreting our findings, it is important to recognize that all polls are subject to sampling error, and results may differ from what might have been found if all physicians in Massachusetts had been polled. The sampling error for this poll is +1.9 percentage points. Possible sources of nonsampling error also include nonresponse bias and effects of the wording and ordering of the questions. As calculated with the use of a standard of the American Association for Public Opinion Research, the response rate was 28%.

In comparing responses among subgroups of physicians, we used t-tests that accounted for the weighting of the data. All reported P values are based on two-sided tests.

1. Yeager DS, Krosnick JA, Chang LC, et al. Comparing the accuracy of RDD telephone surveys and Internet surveys conducted with probability and non-probability samples. August 2009. (Accessed October 21, 2009, at http://www.knowledgenetworks.com/insights/docs/Mode-04_2.pdf.)

2. Keeter S, Kennedy C, Dimock M, Best J, Craighill P. Gauging the impact of growing nonresponse on estimates from a nationalRDD telephone survey. Public Opin Q 2006;70:759-79.

Dr. Blendon reports serving on the board of directors of, and holding stock in, Assurant. No other potential conflict of interest relevant to this article was reported.

Source Information

From the Harvard School of Public Health, Boston (G.K.S., R.J.B., T.S., J.M.C., J.M.B.); the John F. Kennedy School of Government, Cambridge, MA (R.J.B.); and Social Science Research Solutions, Media, PA (M.J.H.).

This article (10.1056/NEJMp0909851) was published on October 21, 2009, at NEJM.org.

References

1. Holahan J, Blumberg L. Massachusetts health care reform: a look at the issues. Health Aff (Millwood) 2006;25:w432-w443. [Free Full Text]
2. Long SK, Phadera L. Estimates of health insurance coverage in Massachusetts from the 2009 Massachusetts Health Insurance Survey. October 2009. (Accessed October 21, 2009, at http://www.mass.gov/Eeohhs2/docs/dhcfp/r/pubs/09/his_policy_brief_estimates_oct-2009.pdf.)
3. Cheplick T, Emanuel J. Massachusetts slashes funds, rations care. Health Care News. September 2009. (Accessed October 21, 2009, at http://www.heartland.org/publications/health%20care/article/25810/Massachusetts_Slashes_Funding_Rations_Care.html.)
4. Blendon RJ, Buhr T, Sussman T, Benson J. Massachusetts health reform: a public perspective from debate through implementation. Health Aff (Millwood) 2008;27:w556-w565. [Free Full Text]
5. American College of Emergency Physicians. ACEP Massachusetts Emergency Physicians Survey. September 17-21, 2009. (Accessed October 21, 2009, at http://www.acep.org/WorkArea/DownloadAsset.aspx?id=46813.)